(Diretor: Dr. J. Garcia) - spandrologia.pt. Uretroplastia com Retalho... · (Diretor: Dr. J. Garcia) Eswara, Urology, 2015 U-score (urethral stricturescore) § Reliable , validated

Uretroplastia com RetalhoRicardo Borges

Serviço de Urologia CHL

(Diretor: Dr. J. Garcia)

Eswara, Urology, 2015

U-score (urethral stricture score)

§ Reliable, validated grading scale

§ Describe the surgical complexity of anterior urethral strictures

§ The stricture’s U-score correlates with surgical time and complexity of procedure required.

§ Valuable tool to grade anterior urethral strictures and improve comparative research

Preoperative Assessment

ObliterativeNon-obliterative

Smith (1968): with normal bladder function, there will be no impact in flowrate until de urethra diameter is <10 French

Important to have a clear anatomical assessment of the site and length of the stricture.

Combined ascending and descending urethrogram to image the urethra, supplemented where necessary by urethroscopy

Preoperative Assessment

The length of urethral narrowing may not correspond directly to the length of ischemic spongiofibrosisTurner Warwick, Urology, 1985

1. Intracorporal injection of contrast

2. Ultrasonography

Chapple, BJU Int, 2004Barbagli, Scand J Urol Nephrol, 1995

Beckert, J Urol, 1991Davies, J Urol. 2009

Clinical role not established!

Recommendations

Urology, 2014

1. The first operation is likely to be the most successful, and preference should be given to the simplest technique that is likely to be most effective, avoiding augmentation urethral reconstruction if possible (Level 3; A).

2. If augmentation (substitution) urethral reconstruction is being considered, an onlayflap for strictures in the penile urethra can also be considered (Level 3; B).

3. In most cases, grafts are preferred over flaps for augmentation urethral reconstruction, particularly in the bulbar urethra, since there is a greater morbidity with the use of flaps compared to with grafts, and they have similar efficacy (Level 2; B).

(…)

Flaps vs. Grafts

§ Time-consuming (and tedious) to harvest

§ Dissection is extensive

§ Scarring and loss of the normal contour of the peniswhen its dartos layer has been redeployed from partor all of its circumference

§ Positive indications in favor of a flap (all of which interfere with the ability of a graft to take):

ü some instances of revision surgery; ü any cause of local devascularization such as

radiotherapy (or severe peripheral vascular disease);

ü local infection

§ Quick and relatively easier to harvest and deploy

§ Inherently less reliable – in theory – because they haveto be revascularized

§ Similar restricture rate as flaps (15,5 e 14,5% respectively)

§ Positive indications:

ü procedure of choice in augmentation when EPA isnot possible

ü Lichen Sclerosus

McAnninch, W J Urol.1998

Recommendations

Urology, 2014

6. Tube substitution procedures should be avoided (Level 3-4; A).

7. Scrotal skin should be avoided where possible because of the high associated morbidity (Level 3; A).

1. Principles of tissue transfer

A flap refers to tissue that is transferred with its native blood supply intact

Jordan, 1992

•

2. Blood supply to the urethra and Penile skin

Dual blood supply to the urethra

allows aggressive mobilization of the spongiosum

Hypospadias (+ severe forms)Prior urethroplasty

Distal blood supply compromised

-> ischemic stenosis

3. Flap techniques

1. Penile skin flaps, are a reliable and time-tested tool for urethral reconstruction

2. Use them correctly:

§ in the absence of prior flap surgery, § nonhirsute penile skin (foreskin and distal penile skin in particular)§ reliable axial vascular supply§ can be well mobilized and used to cover long urethral defects

3. Can be elevated from ventral or dorsal skin and taken in either the longitudinal or transverse direction.

3. Flap techniques

1. Orandi (1968)

§ ventral, longitudinal flap § lateral pedicle§ nonobliterative strictures within the penile

shaft that are not due to BXO§ Success rate: 71.8%

Orandi, J Urol. 1972K J Urol. 2013Adv Urol. 2015

Disadvantage: proximal part of the pendulous or any part of the bulbar urethra: hair-bearing skin is involved in the reconstruction which can lead to recurrent infections and stone formation.

3. Flap techniques

For strictures isolated to the fossa navicularis…

2. Jordan (1987)

§ smaller, ventral penile skin flap that is rotated onto the incised urethral opening§ Success rate: 100% (without LS). 50% (with LS) Jordan, J Urol. 1987

Adv Urol. 2015

a b c d

Blandy, Cohney, Brannen’s modification, SeSy, Devine resurfacing

3. Flap techniques

For longer strictures…

3. Quartey / McAninch

§ both described methods of obtaining penile circular fasciocutaneousisland flap

§ versatile and hairless § can supply enough tissue to cover near panurethral defects. § minimal disfigurement of the penis (circumcision type incision)§ Success rate: 85-90%

§ Modifications:§ Morey - ventral midline extension (Q-flap). § El Dahshoury - zigzag-shaped annular penile fasciocutaneous flap

(modified McAninch flap)Quartey, J Urol. 1985McAninch, J Urol. 1993Buckley, BJUI. 2007

3. Flap techniques

3. Flap techniques

SURGICAL TIPS – CRITICAL STEPS FOR SUCCESS

1. Stretch penile skin during initial widthcalibration for flap development, ideal width 20–25 mm.

2. Elevation of buck’s fascia, support ofthe tunica dartos superficial to theneurovascular bundle.

3. Adequate mobilization of the skin andpedicle flaps.

4. Epithelium to epithelium anastomosis, water tight.

5. Complete stricture incision withcalibration.

SURGICAL PITFALLS

1. Fasciocutaneous flap redundancy –diverticulum formation.

2. Skin necrosis – wrong dissectionplane.

3. Incomplete flap mobilization –ventral bowing of the urethra.

4. Fistula formation – epithelial to epithelial breakdown.

5. Recurrent stricture – inadequatescar incision.

Turner Warwick, Urology, 1985

4. Selecting the right technique

§ Highly individualized

§ Dependent on multiple factors

§ Optimal repair will depend:ü length and location of the strictureü presence or absence of healthy,

abundant penile skinü whether or not the corpus spongiosum is

intact.

§ Decision-making process quite complex;

§ Proper selection of tissue transfer technique is paramount to success.

5. Approach to the appropriate selection of grafts and flaps in urethral reconstruction

Wisenbaugh, Adv Urol. 2015

I. Glans and Fossa Navicularis



II. Penile and Bulbar


Wisenbaugh, Adv Urol. 2015Morey, J Urol. 2001Gelman, J Urol. 2011

III. Special Situations

Segment of obliterated or near-obliterated urethra (not an adequate urethral plate to perform a ventral or dorsal onlay graft):

1. Too long for an EPA or an Augmented anastomosis

2. Short, but at risk of urethral ischemia with urethraltransection (history of hypospadias or failed urethroplasty)

× Tubularized grafts or flaps – high failure rate (58%)ü Graft/Flap combination – success rate of 92% at 39 months



Graft/Flap Combination


Warner, Urology. 2015Wisenbaugh, Adv Urol. 2015Berglung, Urology. 2006


Also useful in:

Panurethral strictures that are too long for repair with BMG even when bilateral grafts are harvested.

… using as much BMG as possible in the proximal aspects of the stricture … penile skin flap to repair the remainder of the stricture distally

• 20 patients

• Success rate: 80% at 40 months

• Avoid urinary diversion/suprapubic tube


J Urol. 2014


Also useful in:

Long segment urethral strictures without a good graft bed (radiotherapy, multiple previous urethral reconstructions).

… use of a well vascularized gracilis muscle flap (GMF) to support a ventral BMG

6. Conclusions

§ Common language (U-score)

§ Adequate preoperative assessment

§ Yes…there is still a role for flaps in the BMG era

§ Criterious selection of technique and tissue transfer (Grafts vs. Flaps)

Documents

(Diretor: Dr. J. Garcia) - spandrologia.pt. Uretroplastia com Retalho... · (Diretor: Dr. J. Garcia) Eswara, Urology, 2015 U-score (urethral stricturescore) § Reliable , validated